Bone and Soft Tissue Infections . . .

A second and third opinion are needed before agreeing to surgery . . .

A Happy/Unhappy tale of three Senior Veterans.

First the “OLD” science.

SALVAGE OF INFECTED AND EXPOSED KNEE PROSTHESIS WITH COMBINED TREATMENT OF SPLINT, ANTIBIOTIC AND HYPERBARIC OXYGENATION.

Ramon, Y; Melamed, Y; Katz, M; Reis, D

“As a last resort the patient was referred for HBO treatment. The patient had 55 sessions of 100% oxygen in 2.4 ATA in a multiplace chamber. RESULTS: Under combined treatment of splinting, antibiotics and HBO the infection resolved and the fistula were closed. 

CONCLUSIONS: A combined treatment that includes HBO should be advised for patients with infected prosthesis before removal.”

http://archive.rubicon-foundation.org/xmlui/handle/123456789/6602

Patient #1 – Happy Outcome:  Rear Admiral (USN retired) (female, 52 y.o., extremely fit – tennis player – lean body weight). Vivacious, lively, and attractive -- but limping along with one leg that did not work. Patient underwent knee replacement surgery at Balboa Naval Hospital. Surgical wounding became infected and I.V. antibiotics were ordered. Loosening of the prosthesis, and flexion contractures plagued this normally active patient. Surgeons recommended more surgery. “Hyperbarics are not indicated” was there expert medical opinion to the patient (Balboa and most other USN Hospitals do not have hyperbaric medicine departments for use of non-diving trauma and illness.)

Nonetheless, the Admiral  decided to seek HBOT at a hospital-quality free-standing center, San Diego Gateway Medical Center Hyperbarics (“SDH”.) On presentation, the knee was “hot and angry” and grossly deformed with pitting edema. Twenty-five consecutive daily HBOT Tx at 2.4 ATA later, the patient considered  herself  “cured” with her knee no longer swollen, zero infection and zero pain. The Center’s Medical Director, Brenton Wynne, M.D.   Muscoskeletal Specialist concurred. 

Justin Lyne-Sands, chamber designer and manufacturer, with transportable recompression chamber system  (TRCS) bound for Malaysian Rescue & Fire Department.

Of note was the Admiral’s astonishment “Hyperaric oxygen therapy is astonishing . . . What? The Navy has $60 million worth of transportable recompression chambers (about 70 systems), some of them in San Diego! Why aren’t the being used at Balboa?


Great Question, Admiral! Why not?

Patient #2  -- Happy outcome:  

Practicing San Diego Medical Doctor. - part of the HCI Scientific Advisory Board (male, 64 y.o., extremely fit from professional dancing, 3% body fat).  Patient underwent knee replacement surgery. Complications set in immediately with an MRSA infection. Again (from a different hospital) the orthopedic surgeon ventured the opinion that “hyperbaric oxygen therapy not indicated." The infection created an open fistula and the patient was in extreme pain. Amputation was being considered.

However, the patient was consulting with  the SDH  Medical Director – Dr. Wynne has multiple specialties, including Pain Management --  and was prescribed HBOT at 2.4 ata. In a three week period, the patient went from wheel chair to walker, then walker to crutches, then to driving himself and walking unassisted to the Center. The M.D. patient continues HBOT therapy to close drain from fistula.

TWO OUT OF THREE AINT BAD

Unhappy outcome --The patient that lost his leg. 

Retired U.S.N.Captain – (76 y.o)  Important note here – the information relayed herein is second hand and Sandsie  can only pass it on as relayed to him by one of the SDH physicians.

Patient underwent knee replacement at Balboa Naval Hospital.  Complications (as described above) were immediate – infection, prosthetic loosening. I.V. antibiotics prescribed. When the patient asked for HBOT sessions (his next door neighbors – both Specialist M.D.’s had recommended this), the orthopedic surgeon again commented “Hyperbaric Oxygen Therapy is  not indicated,” 

After some months of misery, the patient changed to another orthopedic specialist who immediately referred him to the UCSD Hyperbaric Medicine Department. After ten sessions in the chamber, the attending wound care physician made the observation that “no progress in the wound is evident’” and the patient’s leg was amputated! The patient now will spend his last years in a wheel chair!

Sandsie’s Comment: 

While not being present to listen to the decision making milestone of the UCSD medical team and the patient’s response – it is difficult to either condemn nor condone this decision to amputate.

However, in many instances the reimbursement levels for the hospital, insurance providers and personal requirements of the surgical team are a factor in such a surgical decision. Non-the-less, there are many peer-review papers (such as the one above) "approved" and published by the Undersea, Hyperbaric Medical Society (UHMS) that clearly demonstrate that more than ten HBOT treatments are needed for limb-salvage.

Which bring up the terrible plight of the two women with necrotizing fasciitis and the decision to cut and cut and cut.

More “OLD” science.

Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements.

(PMID:2237764) 

Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS

Memorial Medical Center, Southern Illinois University, Springfield.

Surgery [1990, 108(5):847-50]

'The addition of HBO therapy to the surgical and antimicrobial treatment of necrotizing fasciitis significantly reduced mortality and wound morbidity (number of debridements) in this study, especially among nonclostridial infections. 
We conclude that HBO should be used routinely in the treatment of necrotizing fasciitis.'

 http://ukpmc.ac.uk/abstract/MED/2237764/reload=0;jsessionid=qAMDIGsT3OjdEAKDm8jg.34

Hyperbaric oxygen therapy in acute necrotizing infections

with a special reference to the effects on tissue gas tensions.

 Korhonen K.Source: Department of Surgery, University of Turku, Turku, Finland.

 "Between January 1971 and April 1997, 53 patients with Clostridial gas gangrene were treated in the Department of Surgery, University of Turku. The patients underwent surgical debridement, broad spectrum antibiotic therapy and a series of hyperbaric oxygen treatments at 2.5 atmospheres absolute pressure (ATA). Twelve patients died (22.6%). Hyperbaric oxygen therapy in gas gangrene seems to be life-, limb- and tissue saving. Early diagnosis remains essential. Patient survival can be improved if the disease is recognized early and appropriate therapy instituted promptly

When examining the subcutaneous PO2 levels measured from patients with necrotizing fasciitis, the PO2 was regularly higher in the vicinity of the infected area than in healthy tissue. In general, HBO treatment resulted in a marked increase in tissue oxygenation in both healthy tissue and in the vicinity of infected tissue. 
The hyper-oxygenated tissue zone surrounding the infected area may be of significance in preventing the extension of invading microorganisms.

Today's Huffington Post and Reuters

Lana Kuykendall Flesh-Eating Bacteria: 36-Year-Old Mom Has Undergone 7 Operations

"She still has a long road ahead of her," Swaffer said. "We're thankful that the infection is contained to just her legs. Her organs, her vitals are good. She's got a great team of doctors."  A hospital spokesperson said Kuykendall remained in critical but stable condition on Sunday.

Another victim of a flesh-eating infection, 24-year-old Georgia student Aimee Copeland, remained in critical condition on Sunday at Doctors Hospital of Augusta, hospital spokeswoman Barclay Bishop said.


Copeland has had one leg amputated and was told she would have to have her hands and remaining foot removed. The hospital would not confirm whether those surgeries have taken place."

Sandsie's Comment:

World renowned surgeon, Dr. Fredrick Cramer in his book "Hyperbaric Surgery: Perioperative Care" (Best Publishing) is adamant that Gangrene cases go first to a hyperbaric chamber and then surgical debridement,  whereas Necrotzing Fasciitis goes to surgery first and then into a hyperbaric chamber.

Both hospitals  have large hyperbaric medicine departments with chambers that can cope with critical-care, intubated patients. However the media has reported that the Georgia student was finally "approved" for ten HBOT Tx. after 20 days, but only received four of these since there was a concern for "sepsis" by her surgeons.

There has been no confirmation that the Mom with twins has received any HBOT at all.

Again, not being privy to medical considerations, to venture an opinion is  like trying to give a haircut over the telephone. Again, there is a lot of old science that agrees with Dr. Cramer (who has not commented publicly on these two instances.) However, here is another "for-instance."

San Diego Muscoskeletal Pain Speecialist, Brenton Wynne, M.D. at work.

. A  crushing traumatic injury to a 17 year old soccer star.  Surgeon's advice "The toe cannot be saved and we need to amputate most of the foot." The parents chose HBOT -- 25 treatments at the SDH Center and the young man is now playing University soccer -- with all his toes!

NEXT TIME A SURGEON RECOMMENDS IMMEDIATE SURGERY . . . 

                          get that second and third opinion.